Final Case Formulation: Evaluation and Management of Depressive Clinical Manifestations

Final Case Formulation Paper
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Formulation of the Case Study
The case scenario constitutes a comprehensive assessment of a 14-year-old female patient who was referred to the psychiatric unit for evaluation and management of depressive clinical manifestations at the age of seven. The patient is of African American descent, currently in grade eight, and living in a small city with his parents and siblings.
Subjective
The adolescent reported some clinical manifestations, including anxiety and depressive symptoms. Regarding depressive symptoms, the symptoms will be described or reported in this section. The adolescent kept crying frequently and demonstrated excessive worry when the parents were away during weekdays. She also shows some fatigue episodes because she lacks energy, is tired, and is exhausted. The patient also struggles with feelings of worthlessness as she does not exert significant effort to interact with her siblings and peers. She has trouble thinking, as evidenced by constantly waking up at night. Disturbed sleep is a recorded symptom in the adolescent. Regarding anxiety symptoms, the adolescent feels apprehensive and confused. Confusion could be emanating from increased anxiety. In some instances, the patient reported a racing heart despite not engaging in physical activity. The child also has shortness of breath, which could be attributed to anxiety. In addition, the patient frequently demonstrates avoidance because of the rising anxiety levels.
Boland et al. (2021) indicate that it is also crucial to consider the current stressors for the patient. She has serious problems interacting with other children in the classroom. Her emotional state is significantly affecting her studies. Personality conflicts in school are being reported. The patient's schooling problems have resulted in disciplinary action from the teachers. She is experiencing significant relationship strife. The patient has recently experienced separation from her father, who went abroad for work. In addition, significant social issues are reported in adolescents, primarily due to a lack of effective interactions with other children in the neighborhood. It is apparent that the adolescent's emotional state is significantly affecting her social life and ability to maintain effective relationships.
Despite recording deterioration in appetite, the adolescent has not recorded any significant weight loss. There are no gastrointestinal issues recorded. In addition, there are musculoskeletal pains reported in the patient. The patient is not allergic to any medications. This implies that any approved medication can be administered through any route to achieve better health outcomes. The patient did not report surgical history within the previous year. The family has a history of mental health illness as her veteran grandfather struggled with post-traumatic stress disorder. There is no history of mental health in the immediate family.
Objective
Regarding depressive symptoms, the adolescent recorded a lack of concentration in the classroom as well as in home environments. She appears gloomy and withdrawn. The patient is tearful during the session and demonstrates prob...